- The nurse is aware that information derived from a pharmaceutical company’s drug testing to establish therapeutic dose ranges may not be appropriate for the older adult because testing:
| a. | is not done long enough. |
| b. | does not require adequate follow-up. |
| c. | is not well regulated by the U.S. Food and Drug Administration. |
| d. | is usually tested on healthy young persons. |
ANS: D
Long and rigorously regulated drug testing procedures most often use healthy young adults as drug testers.
DIF: Cognitive Level: Comprehension REF: 131 OBJ: 1
TOP: Drug Testing KEY: Nursing Process Step: Planning
MSC: NCLEX: Physiological Integrity: Pharmacological Therapies
- The nurse assesses the older adult patient for evidence of the onset of the effectiveness of an oral preparation because age-related changes in the concentration of gastric acid can:
| a. | change the chemical composition of the drug. |
| b. | increase the distribution. |
| c. | decrease the strength of the drug. |
| d. | retard absorption. |
ANS: D
Decreased gastric acid can decrease the speed of absorption.
DIF: Cognitive Level: Analysis REF: 132 OBJ: 3
TOP: Drug Absorption KEY: Nursing Process Step: Assessment
MSC: NCLEX: Physiological Integrity: Pharmacological Therapies
- The nurse is aware that age-related changes in the stomach that can cause increased drug absorption and possibly toxicity include:
| a. | decreased gastric motility. |
| b. | gastric reflux disease. |
| c. | inability of gastric cells to transport the drug. |
| d. | decreased peristalsis. |
ANS: A
Decreased motility leaves the drug in contact with the gastric mucosa for a longer period of time, which leads to increased absorption. Peristalsis is rhythmic movements of the bowels.
DIF: Cognitive Level: Application REF: 132 OBJ: 3
TOP: Increased Absorption KEY: Nursing Process Step: Planning
MSC: NCLEX: Physiological Integrity: Pharmacological Therapies
- To help prevent lithium toxicity in the older adult, the nurse modifies the nursing care plan to include interventions to:
| a. | increase fluid intake to 3500 mL daily. |
| b. | have the patient ambulate for 10 minutes after the drug is administered. |
| c. | prohibit citrus fruit in the diet. |
| d. | administer a prescribed stool softener to ensure a daily bowel movement. |
ANS: A
Increase of fluids will help allow water-soluble drugs such as lithium to be diluted in the bloodstream more effectively and excreted more rapidly.
DIF: Cognitive Level: Application REF: 132 OBJ: 8
TOP: Distribution KEY: Nursing Process Step: Planning
MSC: NCLEX: Physiological Integrity: Reduction of Risk
- The nurse takes into consideration that as adipose tissue replaces muscle mass in the older adult, a person taking a fat-soluble drug such as diazepam (Valium) several times a day would exhibit:
| a. | tachycardia. |
| b. | a hangover effect. |
| c. | agitation. |
| d. | hypertension. |
ANS: B
Fat-soluble drugs become trapped in the adipose tissue and are slowly released into the bloodstream, increasing the drug’s concentration.
DIF: Cognitive Level: Application REF: 132 OBJ: 3
TOP: Distribution KEY: Nursing Process Step: Planning
MSC: NCLEX: Physiological Integrity: Pharmacological Therapies
- The nurse cautions the older adult who is taking the protein-bound drug warfarin (Coumadin) that, with age-related reduced plasma protein levels, the risk of an adverse reaction is high because:
| a. | unbound active drug molecules continue to circulate in the bloodstream. |
| b. | the bleeding and clotting times will decrease, as evidenced by the PT and INR. |
| c. | the drug becomes ineffective and does not deliver its intended therapeutic action. |
| d. | renal damage can occur from the altered drug molecules. |
ANS: A
Unbound drug molecules will still be circulating, leading to excess drug in the bloodstream. In this situation the bleeding and clotting times will be decreased.
DIF: Cognitive Level: Application REF: 132 OBJ: 3
TOP: Distribution KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity: Pharmacological Therapies
- The nurse frequently assesses the older adult who is on a psychotropic drug for an overdose because:
| a. | older adults are less active. |
| b. | the older adult has fewer cognitive capabilities. |
| c. | brain receptors have become hypersensitive. |
| d. | receptor sites have lower perfusion. |
ANS: C
Brain receptors in the older adult become hypersensitive as age increases, resulting in an exaggerated response to pharmacologic therapy.
DIF: Cognitive Level: Analysis REF: 133 OBJ: 8
TOP: Pharmacodynamics KEY: Nursing Process Step: Assessment
MSC: NCLEX: Physiological Integrity: Pharmacological Therapies
- The major risk of polypharmacy for the older adult is:
| a. | ignorance about his or her prescriptions. |
| b. | taking over-the-counter preparations. |
| c. | being treated by more than one physician. |
| d. | taking old prescriptions rather than consulting a physician. |
ANS: C
Although all the options may offer an opportunity for polypharmacy, the major risk is that of the patient being treated by more than one physician at the same time.
DIF: Cognitive Level: Application REF: 134 OBJ: 4
TOP: Polypharmacy KEY: Nursing Process Step: N/A
MSC: NCLEX: N/A
- The home health nurse would be most concerned about self-medicating errors for the older adult living alone who is a type 1 diabetic and is:
| a. | afflicted with early Parkinson disease. |
| b. | visually impaired. |
| c. | a rheumatoid arthritic with stiffened hands. |
| d. | paralyzed from the waist down. |
ANS: B
The visually impaired diabetic is at the greatest risk for a medication error by incorrectly preparing an insulin injection.
DIF: Cognitive Level: Analysis REF: 134 OBJ: 11
TOP: Sensory Changes KEY: Nursing Process Step: Planning
MSC: NCLEX: Physiological Integrity: Physiological Adaptation
- The medication nurse is aware that the most reliable method of patient identification for administration of medications is:
| a. | a photograph of the patient. |
| b. | an identification bracelet. |
| c. | asking the patient to repeat his or her name. |
| d. | use of the patient’s room number. |
ANS: B
The use of an identification bracelet is the most accurate and reliable method to identify the patient.
DIF: Cognitive Level: Comprehension REF: 142 OBJ: 9
TOP: Patient Identification KEY: Nursing Process Step: Assessment
MSC: NCLEX: Safe, Effective Care Environment: Safety and Infection Control
- The physician has written an order to convert an enteric-coated medication from the pill form to the liquid form. The nurse should:
| a. | transcribe the order and change the medication administration record to show the liquid form. |
| b. | use up the rest of the tablets by crushing them and giving them dissolved in water. |
| c. | order the liquid form from the pharmacy as ordered. |
| d. | inquire if the physician wants the dose to be the same as the pill. |
ANS: D
Because liquids are absorbed more rapidly, the dose might need to be lowered or the schedule of administration changed to avoid an overdose. Enteric-coated medications should not be crushed.
DIF: Cognitive Level: Analysis REF: 143 OBJ: 9
TOP: Liquid Medication KEY: Nursing Process Step: Planning
MSC: NCLEX: Physiological Integrity: Pharmacological Therapies
- When the patient complains that the several pills at the 8 AM dose stick in her throat, the nurse could facilitate administration by:
| a. | suggesting that she take all the pills at one time with a mouthful of water. |
| b. | offering the patient one pill at a time. |
| c. | crushing all the pills and mixing them in the patient’s breakfast cereal. |
| d. | offering a sip of water before and after each pill. |
ANS: D
Offering water before and after administration counteracts the dry mouth that causes the pills to stick. Offering one pill at a time without water does not address the problem of sticking.
DIF: Cognitive Level: Application REF: 144 OBJ: 9
TOP: Pill Administration KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity: Basic Care and Comfort
- The nurse is aware that medicating with transdermal patches requires that the nurse should:
| a. | apply the patch at the same site every day and carry out documentation. |
| b. | fold and dispose of the used patch in the sharps container. |
| c. | warm the patch in his or her hands before application. |
| d. | cover the patch with a light gauze dressing to prevent dislodgement. |
ANS: B
The used patch should be folded with the sticky sides together and disposed of in the sharps container for environmental safety.
DIF: Cognitive Level: Application REF: 145, Box 7 OBJ: 6
TOP: Transdermal Patches KEY: Nursing Process Step: Planning
MSC: NCLEX: Physiological Integrity: Pharmacological Therapies
- When the medication nurse offers a pill to the older adult patient, the patient asks, “What is this and what is it for?” The nurse’s best response would be:
| a. | “I’m not at liberty to discuss your medication. You need to talk to your doctor.” |
| b. | “That’s a ‘feel good’ pill that will make you feel better.” |
| c. | “It’s a cephalosporin that has been ordered to treat your URI.” |
| d. | “It’s an antibiotic for the infection in your urine.” |
ANS: D
Patients have the right to know what they are taking and given a reasonable rationale for its use that they can understand.
DIF: Cognitive Level: Application REF: 146 OBJ: 10
TOP: Right to Know KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity: Basic Care and Comfort
- When the 80-year-old female patient refuses to take a medication because it burns her stomach, the medication nurse should:
| a. | crush the pill and mix it with the dessert on her meal tray. |
| b. | insist that she take it “for her own good.” |
| c. | circle and initial the dose time to show nonadministration. |
| d. | document the reason for refusal and report the refusal to the charge nurse. |
ANS: D
The nurse should carry out documentation of the reason for refusal and report the refusal.
DIF: Cognitive Level: Application REF: 146 OBJ: 10
TOP: Refusal of Treatment KEY: Nursing Process Step: Implementation
MSC: NCLEX: Safe, Effective Care Environment: Coordinated Care
- For the older adult patient receiving the bronchodilator theophylline, the nurse would assess for __________ as evidence of an overdose.
| a. | tachycardia |
| b. | confusion |
| c. | hypotension |
| d. | lethargy |
ANS: A
Tachycardia is a significant side effect of theophylline.
DIF: Cognitive Level: Application REF: 141 OBJ: 7
TOP: Drug Overdose KEY: Nursing Process Step: Assessment
MSC: NCLEX: Physiological Integrity: Pharmacological Therapies
- When the 75-year-old man who has been on a protocol of chlorpromazine (Thorazine) begins to _______ and complain of difficulty swallowing, the nurse notifies the physician.
| a. | cough |
| b. | wheeze |
| c. | drool |
| d. | gag |
ANS: C
Drooling and difficulty swallowing are signs of drug toxicity to chlorpromazine (Thorazine).
DIF: Cognitive Level: Application REF: 141 OBJ: 7
TOP: Drug Toxicity KEY: Nursing Process Step: Assessment
MSC: NCLEX: Physiological Integrity: Pharmacological Therapies
- The nurse preparing to administer 1 mL of vitamin B12 intramuscularly to an emaciated 82-year-old patient would choose a _____-inch needle to inject into the _____ site.
| a. | 1.5; upper outer quadrant of the gluteus maximus |
| b. | 1.5; ventral gluteal |
| c. | 1; deltoid |
| d. | 1; ventral gluteal |
ANS: D
The 1-inch needle to be injected into the ventral gluteal site is the safest choice for the emaciated patient. The location is easily accessible and free from major nerves of vessels. The deltoid is a poor site except for very small dosages.
DIF: Cognitive Level: Application REF: 145-146 OBJ: 9
TOP: Intramuscular Injection KEY: Nursing Process Step: Planning
MSC: NCLEX: Physiological Integrity: Reduction of Risk
- The nurse explains that the Beers criteria provide guidelines for:
| a. | medications best avoided by the elderly independent of diagnosis. |
| b. | diagnostic procedures that are considered inappropriate for a diagnosis. |
| c. | penalties for extended care facilities that allow administration of particular drugs. |
| d. | assessments necessary before the prescription of particular drugs. |
ANS: A
The Beers criteria lists medications best not prescribed for the elderly. The lists are updated regularly, most recently in 2010.
DIF: Cognitive Level: Comprehension REF: 134 OBJ: 5
TOP: Beers Criteria KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity: Reduction of Risk
- The nurse preparing to crush a patient’s oral medications can crush the:
| a. | plain antihypertensive medication tablet. |
| b. | sublingual tablet of nitroglycerin. |
| c. | timed-release capsule for gastric reflux. |
| d. | enteric-coated aspirin. |
ANS: A
Only the plain tablet can be crushed. Timed-release, sublingual medications, and enteric-coated medications should not be crushed.
DIF: Cognitive Level: Application REF: 144, Box 7 OBJ: 9
TOP: Crushing Medication KEY: Nursing Process Step: Planning
MSC: NCLEX: Physiological Integrity: Pharmacological Therapies
MULTIPLE RESPONSE
- The nurse planning to set up a self-medication program for a 70-year-old resident in an extended-care facility will ensure the provision of __________. (Select all that apply.)
| a. | delivery of adequate supply of medication |
| b. | payment for medication |
| c. | locked medication storage at bedside |
| d. | medication administration record |
| e. | assessment of effectiveness of medication |
ANS: A, C, D, E
For self-medication in an extended-care facility, the nurse should make provisions for adequate medication supply, locked storage, medication administration record, and an assessment of the effectiveness of the medication. Payment is not in the purview of the nurse.
DIF: Cognitive Level: Comprehension REF: 146-147 OBJ: 4
TOP: Medication Administration KEY: Nursing Process Step: Planning
MSC: NCLEX: Physiological Integrity: Reduction of Risk
- The nurse includes information in the nursing care plan pertinent to the patient’s needs as they relate to drug administration, which include __________. (Select all that apply.)
| a. | schedule for drawing blood values |
| b. | patient’s need for crushing medication |
| c. | patient’s preference as to the use of medium in which to give crushed medicines |
| d. | schedule of medication and dose times |
| e. | parameters of pulse or blood pressure, if significant to administration |
ANS: A, B, C, E
Schedule and dose information are not considered part of the nursing care plan.
DIF: Cognitive Level: Application REF: 142 OBJ: 8
TOP: Medication Information in the Nursing Care Plan
KEY: Nursing Process Step: Planning
MSC: NCLEX: Physiological Integrity: Pharmacological Therapies
- The home health nurse reviews all medications of a patient because the nurse is aware that with the high cost of prescription drugs, older adults will __________. (Select all that apply.)
| a. | simply not fill a new prescription |
| b. | take less than prescribed to preserve their supply |
| c. | fill all prescriptions at once to get a discount |
| d. | save old prescription drugs for later use |
| e. | share medications |
ANS: A, B, D, E
Filling prescriptions at one time can be costly even with a discount; therefore the older adult may pick and choose which ones to fill. All the other behaviors listed are methods whereby persons on a limited budget will attempt to preserve their supply of medications and contain costs.
DIF: Cognitive Level: Application REF: 140 OBJ: 12
TOP: Risks Related to Financial Factors KEY: Nursing Process Step: Implementation
MSC: NCLEX: Psychosocial Integrity: Coping and Adaptation
- The nurse is aware that the older adult is more at risk for medication-related problems related to __________. (Select all that apply.)
| a. | drug-testing methodology |
| b. | age-related changes |
| c. | polypharmacy |
| d. | cognitive and sensory changes |
| e. | lack of adequate medical follow-up |
ANS: A, B, C, D
Lack of follow-up is not identified as a factor in medication-related problems.
DIF: Cognitive Level: Comprehension REF: 132 OBJ: 1
TOP: Factors in Medication-Related Problems KEY: Nursing Process Step: N/A
MSC: NCLEX: N/A
- The nurse reminds the older adult that self-medication with OTC drugs can be hazardous because OTC drugs can __________. (Select all that apply.)
| a. | increase the effect of a prescribed drug |
| b. | interfere with the efficacy of a prescribed drug |
| c. | mask significant symptoms of primary disease |
| d. | create symptomatology of their own |
| e. | cause overdose because they are not considered to be “real drugs” |
ANS: A, B, C, D, E
The overuse of OTC drugs can cause all these medication-related problems.
DIF: Cognitive Level: Comprehension REF: 139 OBJ: 11
TOP: Overuse of OTC Drugs KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity: Pharmacological Therapies
- The nurse crushes a pill and disguises the dose in the mashed potatoes of a resident in a long-term care facility who previously refused the drug. It is then fed to the patient by the nursing assistant. This should be considered an error because it __________. (Select all that apply.)
| a. | violates the patient’s right to refuse medication |
| b. | involves delegation of medication administration to the nursing assistant |
| c. | increases the amount of time for the drug administration pass |
| d. | becomes impossible to confirm the patient received the entire dose |
| e. | alters the food |
ANS: A, B, D
Hiding a dose of drug in a food serving that the patient had previously refused is unethical. Delegating the administration of a drug to a nonqualified person is illegal, and because there is no guarantee the entire serving of food will be consumed, the intended dose may not be delivered.
DIF: Cognitive Level: Application REF: 145 OBJ: 9
TOP: Disguising Drugs in Food KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity: Pharmacological Therapies
COMPLETION
- The nurse informs a group of older adults that ____% of all prescriptions are written for adults age 65 and older.
ANS: 40
DIF: Cognitive Level: Knowledge REF: 131 OBJ: 1
TOP: Recipients of Prescriptions KEY: Nursing Process Step: N/A
MSC: NCLEX: N/A
- The nurse clarifies that the term __________ refers to the study of how persons respond to medicines.
ANS: pharmacodynamics
DIF: Cognitive Level: Knowledge REF: 132 OBJ: 4
TOP: Medicating the Older Adult KEY: Nursing Process Step: N/A
MSC: NCLEX: N/A
- The primary organ of drug metabolism is the __________.
ANS: liver
DIF: Cognitive Level: Knowledge REF: 133 OBJ: 3
TOP: Drug Metabolism KEY: Nursing Process Step: N/A
MSC: NCLEX: N/A
- The home health nurse periodically interviews patients relative to their use of _________ because it is the most commonly consumed and abused nonprescription drug used by adults.
ANS: alcohol
DIF: Cognitive Level: Comprehension REF: 139 OBJ: 11
TOP: Use of Alcohol KEY: Nursing Process Step: Assessment
MSC: NCLEX: Physiological Integrity: Pharmacological Therapies
OTHER
- Arrange the steps for preparing crushed medications to be given by feeding tube in order of priority.
- Flush the tube to clear feeding.
- Thoroughly crush the medication.
- Administer each medication separately.
- Dissolve each crushed medication in a medicine cup.
- Flush the tube to clear the medication from the tube.
- Reconnect the feeding tube.
ANS: B, D, A, C, E, F
DIF: Cognitive Level: Application REF: 145 OBJ: 6
TOP: Crushed Medication per Tube KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity: Pharmacological Therapies
Wold: Basic Geriatric Nursing, 5th Edition
Chapter 09: Meeting Safety Needs of Older Adults
Test Bank
MULTIPLE CHOICE
- The nurse cautions the older man who has diminished depth perception that he will have difficulty:
| a. | judging the height of steps. |
| b. | reading small print on food labels. |
| c. | reading street signs. |
| d. | seeing in dim light. |
ANS: A
Diminished depth perception results in an inability to judge height and depth of steps and judge distance. These deficits result in falls.
DIF: Cognitive Level: Knowledge REF: 167 OBJ: 1
TOP: Diminished Depth Perception KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity: Physiological Adaptation
- The home health nurse helps the family improve the safety of the environment for the 85-year-old male patient with Parkinson disease who is at risk for falls related to:
| a. | postural hypotension. |
| b. | cognitive changes. |
| c. | altered vision. |
| d. | altered gait. |
ANS: D
The propulsive gait and reduced ability to lift the feet make falls a constant threat to a patient with Parkinson disease.
DIF: Cognitive Level: Application REF: 167-168 OBJ: 3
TOP: Fall Prevention KEY: Nursing Process Step: Implementation
MSC: NCLEX: Safe, Effective Care Environment: Safety and Infection Control
- The nurse reminds the older adult who is taking drugs for hypertension that to prevent falls from orthostatic hypotension, the patient should:
| a. | ambulate with a walker. |
| b. | avoid hot baths. |
| c. | avoid climbing stairs. |
| d. | sit on the side of the bed for a moment before ambulation. |
ANS: D
Sitting on the side of the bed before ambulation gives the vascular system time to adjust to a positional change.
DIF: Cognitive Level: Application REF: 169, Box 9-2
OBJ: 2 TOP: Fall Prevention
KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity: Pharmacological Therapies
- The nurse is aware that some older adults deny that they have fallen because they fear that they will:
| a. | fall again. |
| b. | be hospitalized for treatment. |
| c. | be seen as frail and dependent. |
| d. | be considered clumsy. |
ANS: C
Many older adults do not report falls because they fear that they will be seen as frail and dependent.
DIF: Cognitive Level: Application REF: 168 OBJ: 2
TOP: Fall Prevention KEY: Nursing Process Step: Planning
MSC: NCLEX: Psychosocial Integrity: Coping and Adaptation
- After the 82-year-old female patient fell in her home, the home health nurse interviewed her about the incident because the information will:
| a. | be reflected in the home health nurse’s documentation. |
| b. | help the patient gain insight into the cause of the fall. |
| c. | be used to guarantee no further falls. |
| d. | be collected for research purposes. |
ANS: B
Gaining insight into the cause of falls will help the patient and family become aware of factors in the home that are so familiar that they are not seen as hazards. Recognition of hazards will lead to an alteration of the environment for improved safety.
DIF: Cognitive Level: Application REF: 169, Box 9-2
OBJ: 3 TOP: Fall Prevention
KEY: Nursing Process Step: Assessment
MSC: NCLEX: Safe, Effective Care Environment: Safety and Infection Control
- The nurse is aware that a fall prevention exercise program for the residents in a long-term care facility is focused on:
| a. | improving balance. |
| b. | use of assistive devices. |
| c. | improving circulation. |
| d. | increase in the knowledge base about falls. |
ANS: A
Most exercise programs are focused on improvement of balance to reduce the incidence of falls. Improved balance is seen as an effort to improve the confidence of the older adult.
DIF: Cognitive Level: Comprehension REF: 168 OBJ: 3
TOP: Fall Prevention KEY: Nursing Process Step: Planning
MSC: NCLEX: Physiological Integrity: Physiological Adaptation
- The daughter of an older adult asks the home health nurse for advice in selecting a cane for her 80-year-old mother, who has an unsteady gait. The cane that would be least appropriate would be a:
| a. | wooden cane with a rubber tip. |
| b. | four-footed cane with a rubber grip. |
| c. | clear acrylic cane with a nonslip tip. |
| d. | colorful carved cane with a wooden tip. |
ANS: D
The lack of a nonskid tip makes the colorful carved canes an inappropriate choice.
DIF: Cognitive Level: Application REF: 169, Box 9-2
OBJ: 3 TOP: Assistive Devices
KEY: Nursing Process Step: Implementation
MSC: NCLEX: Safe, Effective Care Environment: Safety and Infection Control
- A caring home health nurse has given his 90-year-old patient a framed poster that says, “Pride goeth before a fall” to remind his patient to:
| a. | take care not to fall. |
| b. | ask for assistance when needed. |
| c. | take pride in his independence. |
| d. | not attempt any activity without help. |
ANS: B
Asking for assistance is good judgment rather than attempting risky acts without help.
DIF: Cognitive Level: Application REF: 169, Box 9-2
OBJ: 3 TOP: Fall Prevention
KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity: Physiological Adaptation
- The nurse in a long-term care facility teaches tai chi for 15 minutes a day to the residents to:
| a. | stimulate their intellectual activity. |
| b. | encourage interaction. |
| c. | improve coordination. |
| d. | demonstrate cultural awareness. |
ANS: C
Tai chi is a low-impact, nonstressful exercise that develops balance and coordination.
DIF: Cognitive Level: Knowledge REF: 169, Cultural Considerations
OBJ: 3 TOP: Fall Prevention
KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity: Physiological Adaptation
- The home health nurse assesses the home for potential fire hazards and identifies the hazard of:
| a. | baking soda near the stovetop. |
| b. | a smoke detector in the kitchen. |
| c. | multiple appliances plugged into one outlet. |
| d. | extension cords coiled up behind furniture. |
ANS: C
Multiple electrical appliances plugged into one outlet can create an overload and cause a fire.
DIF: Cognitive Level: Analysis REF: 170 OBJ: 3
TOP: Fire Hazard KEY: Nursing Process Step: Assessment
MSC: NCLEX: Safe, Effective Care Environment: Safety and Infection Control
- When the 80-year-old woman brags about her new deadbolt lock, the home health nurse suggests that while she is inside, she should:
| a. | keep the door securely locked. |
| b. | apply similar locks on the windows. |
| c. | leave the door unlocked, with the key in place. |
| d. | replace the lock with a security chain. |
ANS: C
Unlocked deadbolts allow rapid access by emergency personnel.
DIF: Cognitive Level: Application REF: 171, Box 9-4
OBJ: 3 TOP: Home Safety
KEY: Nursing Process Step: Implementation
MSC: NCLEX: Safe, Effective Care Environment: Safety and Infection Control
- The home health nurse has evaluated the home of an older adult for factors that could be improved to increase home security and found all the following. Of these, the finding that would least improve home security would be a:
| a. | peephole in the door at a convenient height. |
| b. | brightly lit porch. |
| c. | large dog with a loud bark. |
| d. | hook and eye latch on the screen door. |
ANS: D
The hook and eye latch on the screen door, although a retardant, would not offer adequate security in the case of a break-in.
DIF: Cognitive Level: Analysis REF: 171, Box 9-4
OBJ: 3 TOP: Home Security
KEY: Nursing Process Step: Assessment
MSC: NCLEX: Safe, Effective Care Environment: Safety and Infection Control
- The home health nurse counsels a family in making “rules” for their 85-year-old father for driving safety. The rule that would be inappropriate would be to:
| a. | limit driving to nearby areas with easy access. |
| b. | plan ahead and know where you are going. |
| c. | wear prescribed glasses and hearing aids. |
| d. | drive below the speed limit to maintain control of the car. |
ANS: D
Driving “rules” are significant when there are no alternatives to driving. Driving slowly causes accidents.
DIF: Cognitive Level: Application REF: 172, Box 9-5
OBJ: 3 TOP: Driving Safety
KEY: Nursing Process Step: Implementation
MSC: NCLEX: Safe, Effective Care Environment: Safety and Infection Control
- The home health nurse points out that older persons may have a thermoregulation disturbance that makes them feel cold related to:
| a. | reduced activity. |
| b. | eating highly spiced foods. |
| c. | being overweight. |
| d. | hyperglycemia. |
ANS: A
Reduced activity, lower basal metabolism rate, and slowed circulatory rate contribute to the feeling of being cold.
DIF: Cognitive Level: Comprehension REF: 172, Box 9-6
OBJ: 7 TOP: Thermoregulation Disorder
KEY: Nursing Process Step: Assessment
MSC: NCLEX: Physiological Integrity: Physiological Adaptation
- The nurse confirms that the older adult is suffering from heat exhaustion when the nurse assesses:
| a. | excessive perspiration. |
| b. | bradycardia. |
| c. | temperature of 100° F. |
| d. | leg cramps. |
ANS: D
Persons with heat exhaustion have leg and abdominal cramps; dry, hot, nonperspiring skin; tachycardia; and a temperature over 102° F.
DIF: Cognitive Level: Application REF: 174 OBJ: 6
TOP: Heat Exhaustion KEY: Nursing Process Step: Assessment
MSC: NCLEX: Physiological Integrity: Physiological Adaptation
- The nurse is aware that the older adult is at greater risk for hypothermia than a younger person because the older adult has a diminished ability to:
| a. | convert glycogen to glucose. |
| b. | select appropriate clothing or bed linen. |
| c. | shiver. |
| d. | constrict vessels. |
ANS: C
Older adults have a diminished ability to shiver. Shivering is a muscular activity that increases metabolism and body heat.
DIF: Cognitive Level: Comprehension REF: 173 OBJ: 4
TOP: Thermoregulation KEY: Nursing Process Step: Planning
MSC: NCLEX: Physiological Integrity: Physiological Adaptation
- The nurse volunteering in a homeless shelter is aware that when a person with severe hypothermia is admitted, interventions should include:
| a. | giving the person hot coffee or soup. |
| b. | placing the person in a warm bath. |
| c. | briskly rubbing the person’s hands. |
| d. | wrapping the person in blankets. |
ANS: D
The hypothermic individual should be moved to a warmer environment, wrapped in blankets or other insulating material, and given warm, not hot, drinks or food. Putting an individual in a warm bath may cause cardiovascular problems or skin damage.
DIF: Cognitive Level: Knowledge REF: 174 OBJ: 4
TOP: Thermoregulation KEY: Nursing Process Step: Planning
MSC: NCLEX: Physiological Integrity: Physiological Adaptation
- To help prevent a fall while caring for a confused 86-year-old resident in an extended-care facility, the nurse’s initial choice would be:
| a. | use of a vest restraint. |
| b. | use of an electronic sensor alarm. |
| c. | placement of a wheelchair between the wall and dining table. |
| d. | a tray table attached to the arms of the wheelchair. |
ANS: B
The alarm is the best initial choice because it does not require a physician’s order. The vest restraint requires an order. The tray table and “trapping” the resident between the wall and a dining table may lead to injuries as the resident attempts to get out of confinement.
DIF: Cognitive Level: Comprehension REF: 176 OBJ: 3
TOP: Restraints KEY: Nursing Process Step: Planning
MSC: NCLEX: Physiological Integrity: Reduction of Risk
MULTIPLE RESPONSE
- The home health nurse coaches the older adult about what to do in case of a home fire. The nurse would encourage the older adult to __________. (Select all that apply.)
| a. | keep a flashlight at the bedside |
| b. | use an appropriate fire extinguisher to control fire |
| c. | keep the doors open for an easy escape route |
| d. | call 911 before exiting the home |
| e. | open the windows to decrease smoke |
ANS: A
Keep a flashlight for emergency lighting in case of dense smoke or an electrical failure. Do not try to extinguish the fire, close doors and windows to prevent spread of fire, and call 911 after exiting the building.
DIF: Cognitive Level: Application REF: 170 OBJ: 3
TOP: Fire Safety KEY: Nursing Process Step: Implementation
MSC: NCLEX: Safe, Effective Care Environment: Safety and Infection Control
- The nurse clarifies internal factors that threaten the safety of the older adult, which include __________. (Select all that apply.)
| a. | decrease in flexibility |
| b. | slowed reaction time |
| c. | gait changes |
| d. | thermal hazards |
| e. | postural changes |
ANS: A, B, C, E
Thermal hazards are not internal risk factors. All other options listed are internal risk factors.
DIF: Cognitive Level: Comprehension REF: 168-169 OBJ: 2
TOP: Internal Hazards KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity: Physiological Adaptation
- The nurse in a long-term care facility awards Fall Guy stickers to certified nursing assistants who consistently __________. (Select all that apply.)
| a. | report broken tiles in the shower room and bathrooms |
| b. | mop up spills |
| c. | assist residents to hurry |
| d. | remind residents to use walkers |
| e. | retie residents’ shoelaces |
ANS: A, B, D, E
Hurrying the older adult increases the risk for falls. All other options promote safety for the older adult.
DIF: Cognitive Level: Application REF: 169 OBJ: 3
TOP: Fall Prevention KEY: Nursing Process Step: Implementation
MSC: NCLEX: Safe, Effective Care Environment: Safety and Infection Control
- The home health nurse identifies environmental hazards and personal practices of the 80-year-old woman that need to be modified to decrease the risk of falls, which are __________. (Select all that apply.)
| a. | brightly lit rooms |
| b. | pantry food at an accessible level |
| c. | colorful scatter rugs marking doorways and steps |
| d. | wearing comfortable laced tennis shoes |
| e. | attractive, low, magazine rack beside a chair |
ANS: C, E
Scatter rugs and low items placed near the bed or chairs are fall hazards. All the other options listed promote safety at home.
DIF: Cognitive Level: Application REF: 170, Box 9-3
OBJ: 3 TOP: Fall Prevention
KEY: Nursing Process Step: Assessment
MSC: NCLEX: Safe, Effective Care Environment: Safety and Infection Control
- The nurse lists external risk factors that may be a threat to the older adult, including __________. (Select all that apply.)
| a. | fire hazards |
| b. | lack of home security |
| c. | vehicular accidents |
| d. | thermal hazards |
| e. | sensory deficit |
ANS: A, B, C, D
Sensory deficits are not external risk factors. All other options listed are.
DIF: Cognitive Level: Knowledge REF: 170, Box 9-3
OBJ: 2 TOP: External Risk Factors
KEY: Nursing Process Step: Implementation
MSC: NCLEX: Safe, Effective Care Environment: Safety and Infection Control
- The home health nurse suggests telephone modifications to increase the safety of older adults, which are __________. (Select all that apply.)
| a. | placement of phones at bedside and next to a favorite chair |
| b. | programming an auto dial function for quick dialing |
| c. | using an answering machine with a male voice |
| d. | replacing the phone cord with a 15-foot cord for ease in carrying around the phone |
| e. | selecting a phone with large numbers |
ANS: A, B, C, E
Long cords are a fall hazard. All other options increase safety of the older adult.
DIF: Cognitive Level: Application REF: 171, Box 9-4
OBJ: 3 TOP: Phone Safety
KEY: Nursing Process Step: Implementation
MSC: NCLEX: Safe, Effective Care Environment: Safety and Infection Control
- The home health nurse has evaluated the community for measures that support pedestrian safety and identifies pedestrian safety measures, including __________. (Select all that apply.)
| a. | pedestrian-controlled crosswalks |
| b. | safety islands on wide street intersections |
| c. | free vehicular turning at all intersections |
| d. | clearly marked crosswalks at intersections |
| e. | overhead crossings over busy streets |
ANS: A, B, D, E
Free vehicular turning at intersections is a hazard for the older adult pedestrian. All other options listed promote pedestrian safety.
DIF: Cognitive Level: Application REF: 171 OBJ: 3
TOP: Prevention of Vehicular Accidents KEY: Nursing Process Step: Assessment
MSC: NCLEX: Safe, Effective Care Environment: Safety and Infection Control
- The nurse lists factors that increase the risk of vehicular accidents for the older driver, which are __________. (Select all that apply.)
| a. | safety islands in the street |
| b. | cognitive disorders |
| c. | altered depth perception |
| d. | changes in night vision |
| e. | reduced flexibility |
ANS: B, C, D, E
Safety islands in the street are a safeguard against accidents. All other options listed put the older adult at risk for accidents.
DIF: Cognitive Level: Knowledge REF: 171 OBJ: 2
TOP: Vehicular Hazards KEY: Nursing Process Step: Implementation
MSC: NCLEX: Safe, Effective Care Environment: Safety and Infection Control
- The distraught daughter of a 92-year-old man who still drives shares observations with the home health nurse indicative of his deteriorated driving skills, which are __________. (Select all that apply.)
| a. | paint scrapes on the mailbox at the curb |
| b. | friends calling him to get rides to the grocery store |
| c. | choosing not to drive at night because of night blindness |
| d. | difficulty turning his head |
| e. | carefully planning routes to avoid heavy traffic |
ANS: A, D
Paint scrapes suggest depth perception difficulty, and inability to turn the head makes backing up and checking for cross traffic difficult.
DIF: Cognitive Level: Comprehension REF: 172 OBJ: 3
TOP: Driving Safety KEY: Nursing Process Step: Assessment
MSC: NCLEX: Safe, Effective Care Environment: Safety and Infection Control
COMPLETION
- The nurse takes into consideration that the most common injuries to the older adult are the result of __________.
ANS: falls
DIF: Cognitive Level: Knowledge REF: 167 OBJ: 1
TOP: Falls KEY: Nursing Process Step: Planning
MSC: NCLEX: Safe, Effective Care Environment: Safety and Infection Control
